Healthcare Provider Details

I. General information

NPI: 1124162300
Provider Name (Legal Business Name): CAROLYN BOONE LEWIS HEALTH CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 SOUTHERN AVE SE
WASHINGTON DC
20032-4623
US

IV. Provider business mailing address

1380 SOUTHERN AVE SE
WASHINGTON DC
20032-4623
US

V. Phone/Fax

Practice location:
  • Phone: 202-279-5828
  • Fax:
Mailing address:
  • Phone: 202-279-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberB131064
License Number StateDC

VIII. Authorized Official

Name: MR. JOSEPH B TUCKER
Title or Position: SR VICE PRESIDENT/CFO
Credential:
Phone: 301-686-9010